Megan W 

All right, so I will go ahead and introduce you guys, and we'll, we'll get started. So Hi everybody, welcome. I can't believe it's already our like, 10th or 11th clinical exchange. We're like, well into it as the winter months are rolling in, It's just been, I was just like, I was just saying, just such a lovely way to spend our lunch hour and learn so much from from all of you experts in the field, and as a learner myself, I'm always just so excited to continue to grow, and so we're really excited to have both of you guys with us today. So Dr Michele Foster and Dr Nina Mafrici will be talking about eating disorders and essentials for clinicians today. So they are clinical psychologists and the co-directors of Toronto Psychology and Wellness Group, their clinical practice focuses on supporting adolescents and adults struggling with difficulties pertaining to emotion regulation and eating disorders. TPYG is the first outpatient, non hospital based eating disorders program in Ontario to provide OHIP covered physician care alongside of psychological an dietetic treatment across the lifespan. So just taking a second to let that sink in, but that's how incredible that is Created with the vision of reducing gaps in healthcare and providing a patient centered approach to evidence based treatment. TPYG's ed program has successfully guided children, adolescents and adults towards successfully achieving recovery. Doctors Foster and Mafrici had the unique experience of working together throughout their graduate training, from doctoral rotations and sick kids eating disorders program to residencies at Ontario, excuse me, Ontario Shores Center for Mental Health Sciences, though in different programs and supervised practice within private clinics focused on assessment and comprehensive DBT, they fostered a meaningful and supportive partnership, ultimately completing doctoral Graduate Studies at the University of Toronto. So clearly, you guys know so much about this, and are well built first, and we love to see and we're excited to hear what you guys have to share today. So I'll let you take it. Take it away.

Dr. Nina Mafrici 

Thanks so much for the lovely introduction, Megan. Okay, so today we're, you know, we could talk about this for hours on hours and hours and end so we know we have, I've got to keep my my clock here, so that we keep on a good timeline, and then we can open things up to questions. So we're going to talk briefly about evidence based approaches in the treatment of eating disorders, a lot of which we, you know, have learned throughout our course of clinical practice and as well as our research, as well as in the development of our program at TPWG. So just to go through what we're going to be talking about, a little bit about today is the intake process, some of the early interventions that we use at the start of treatment, as well as some of the CBT and DBT interventions, which we primarily use at the clinic in the course of eating disorder treatment, both for adolescents and adults. And we're also going to talk about involving others in care, whether this is through a multi disciplinary practice like ourselves, or whether you are working with folks with eating disorders individually in the community, collaboration with other people in the treatment approach is essential we find to to positive treatment outcomes. So we'll talk a little we'll end a little bit with with that information. So I'll begin by talking a little bit about the goals for the intake assessment. As a lot of folks know, the intake is a really important process for any clinical issue in terms of gaining information about what's been happening, the severity of the problem, and how we're going to work on treating it in eating disorders. Specifically, there's a number of really important facets that we want to cover in the intake assessment that may be different from some typical assessment. So we're really gearing towards understanding the nature and severity of the eating problem itself, which helps to inform what approach we're actually treating, and also the different level of care that we're going to be assigning to sort of the treatment. We want to also understand the level of motivation and insight that the individual has with respect to the eating problem, developing a shared understanding of it, and it's really also a unique opportunity to provide psycho educational information, as well as dispelling common myth about eating disorders, building trust and engagement. This is true for both adults seeking eating disorder treatment, as well as adolescents and involving parents and caregivers in building their trust and engagement, which is essential to the progress of positive treatment recovery. So with the intake process, we always begin with a very comprehensive psychosocial interview. Adjunct services that we use in conjunction with the psychosocial interview include a dietetic interview as well as a comprehensive medical assessment to determine sort of physical health status, as well as any other comorbid medical issues that may or may not be related to the eating disorder. And really this, this comprehensive intake process allows us to have more clarity on the severity maintaining factors related to the eating problem, in order to develop things like, what are our primary priority targets, and what are the goals that we're going to be developing to target those specific primary facets, it also helps us in terms of understanding what type of dose of treatment is needed and the professional involvement that is necessary. So some folks, for instance, require ongoing medical monitoring on a weekly or bi weekly basis at the start. Other people might not require that some might require weekly dietetic assessments, or, I should say sorry, dietetic appointments, whereas other people may not need as much involvement. And it also helps to improve patient safety and reduce liability. So when we have folks, and especially since COVID, that are coming in more sick than ever that we would typically not see on an outpatient basis, folks with BMI of 15 or less, many folks who come in with or unstable, orthostatic vitals that need to be sent to the emergency room upon the medical assessment. Many of these individuals, we didn't have that kind of information before we started working with physicians and nurse practitioners in house. So in terms of some of these topics that are covered during intake, we're looking at the development of the eating problem, and this includes the onset and likely triggers, the course of the illness, evolution of the problem. What is the weight history? Right? This is really essential to determining things like target weight ranges, or, as we call them, wellness weights, when an individual specifically has been experiencing restrictive eating disorders like anorexia, experiences in prior treatment. Many, if not most, of our incoming clients have had some exposure to previous treatment, whether that's in a hospital or whether on an outpatient basis. We also want to understand the current state of the eating problem. So eating habits in a typical day, good day versus a bad day, in their mind, any diets, dietary restraint, restriction, other weight control behaviors, other eating habits, things like chewing and spitting, rumination, ritualistic eating, and whether the individual has an ability to eat socially, whether that's at school or work. We also want to understand body image really, really essential to any eating disorder, with the exception of basically ARFID is really, if there is a preoccupation with shape and weight, what are the views on shape and weight? Is there a goal weight that the person has the importance of the appearance and self evaluation. So we know eating disorders, again, with the exception of ARFID, really have that, that defining feature of this importance of the appearance and weight and body weight and shape on one self concept, or self worth, body checking, weighing mirror, use other forms of checking or body avoidance. Comparison to other people, this feeling, quote, unquote fat, which we know fat is not a feeling physical health. So current physical health status, including last menstrual period for those for girls and women, general medical history, current medication, including the use of birth control pills or other SSRIs or SNRIs. And developmental history is essential, especially with our adolescent population, a personal and family history, family eating disorders and obesity history, I would say about 50% of the individuals that come into our clinic do have a history a family history of eating disorders. Many folks that come in have parents that are engaging in their own weight control behaviors, bullying or teasing due to weight family focus on dieting, weight or exercise and other comorbidities. As we know, eating disorders do not occur in silos. So oftentimes there's comorbid anxiety, depression, ASD, ADHD, effects on functioning. So what is the impact of the eating problem on things like psychological, social functioning, academic functioning, occupational functioning, effects on mood and concentration, effects on other people, whether it's partner, family, friends, acquaintances, and the effects on activities and interests? we also want to understand the attitude to the eating problem. So what are the views that the individual has on keeping that eating problem going, the attitude on starting treatment, on concerns about treatment and the prospect of potentially changing goals and hopes for treatment. So vast majority of people that come in for eating disorder treatment really don't like the behaviors that they're engaging in. They don't like how distressed that they're feeling, but they have a very, very strong resistance to wanting to change behaviors that might alter weight or shape in any way. parents own eating history and body image concerns, as we spoke about before, and what our parents hope for treatment, right? And what do they think that their family needs to be successful in treatment as well as reviews of boundaries, safety, confidentiality, and this is an important one. So just like when we have an adolescent who might, you know, be high risk for self harm or suicidality, you know, we do inform both the adolescent and parents that if we, we know, we receive information that the individual may be potentially putting their life at risk, and this is often the case with things like purging behavior that we will have to involve parents.

Dr. Michele Foster 

Okay, so we're going to shift. And you know, you can hear me, right? I can just Yes, okay, perfect, perfect. Thank you. One of the things I was just going to say before we shift to debunking myths is that very often in eating disorder work, we have to define the limits of confidentiality a little bit differently, right? So when we talk about risk to self or risk to others, what does that look like in the context of eating disorder work, and even when working with teens, we choose to say, really, at the outset of treatment, that if they're coming in because they are forced to come in, but they don't want to work on anything, and they're sitting in silence or refusing to engage, that that's a conversation that we do have with the family. And we might not give specifics, but we will say that, you know, they're not, they're not doing the work so that we can problem solve. So we let people know that from the beginning, just because of the life threatening nature of eating disorders, sometimes you have to make little shifts to that. So I just wanted to highlight that. So debunking myths. Myths are really important for us to understand and be able to catch when treating eating disorders, and there are tons of them, but we picked a couple kind of very common ones. So first is this idea that eating disorders seem to be primarily about food, eating weight and shape. And I think there's truth to that on the surface, but it's like an iceberg, right? So if that's how you define an eating disorder as a clinician, you're going to end up missing the whole picture, or the majority of the picture. Really, what eating disorders are are the external expression of underlying suffering, and it's that internal experience that's really comprised of emotional conflicts and dysregulation that an individual doesn't necessarily know how to cope with or that they fear. But the eating disorder, because it takes up so much brain space, and that's rooted in, you know, our own evolution is we get cravings, and we long for certain things when we're hungry, and so it works really well as a way to distract, to numb until it doesn't right, because it causes a number of different consequences. And so what do we see as sort of the lower part of the iceberg, things like feeling starved for care and affection, wanting to be protected and cherished or valued, feelings of failure, weakness, a lot of shame. Shame is probably one of the predominant emotional experiences in eating disorders, we see lots of feelings of being ineffective, unworthy, unlovable, being abandoned as a result of that, or fear of being abandoned, and lots of anger and aggression that are then muted or minimized because of invalidation, which then becomes sort of this, this self invalidation, or confusion about what those emotions mean, or the right to experience them or express them. Another one is that eating disorders are really just a choice, and it's a lifestyle and it's a way of being. And it's not a big deal. This is absolutely a myth. So we know that eating disorders are not a choice, and part of our role as clinicians is to help sufferers and those around them really understand that it's not something somebody is choosing to do to cause suffering or to get attention or because they're vain. It really has to do with so much more, and it's because eating disorders are so effective that the behavior that is innate to them is really highly reinforcing. And so it becomes this rolling snowball, so to speak, right? That's very hard to stop. It's not about vanity, and we really help them try to understand how they develop by pulling on the biopsychosocial theory. So essentially recognizing that there are biological elements, there are psychological elements, and social elements, cultural elements, all sorts of things that kind of come together. And we use this metaphor of like the perfect storm, where something can trigger it, it sets it off, and that then leads to the development of an eating disorder, which, you know, they are very, very treatable. It just sort of depends on a number of factors, including how long it's been going on, what's reinforcing it, and, you know, a number of different things. So typically, when somebody comes in for eating disorder treatment, we we spend some time trying to understand where they're at in their readiness to change. And I think, you know, I'm sure you guys are familiar with this, regardless of what you treat, right, which is sort of that readiness to actually engage and start creating that change. But what makes eating disorders unique is that we see such a high volume of folks in pre contemplation. And there's a number of reasons for this. One, I think a lot of the focus on body and appearance is highly reinforced in society, and so very often their behaviors have been reinforced, whether inadvertently or not. But also, you know, there's that, there's a part of folks who want to maintain the eating disorder. And so if you think about somebody coming in to see you for depression, they'll often say something like, I feel terrible, help me feel better, right? But if somebody's coming to see you for an eating disorder, it's, I feel terrible, and make me feel better, but please, I don't want to gain weight. And so there's sort of this but, or this exception very often, to the rule of what they're looking for, and that makes treating it much, much harder. And so we recognize that about 75% of the people who come in for eating disorder treatment are at that pre contemplation state, they're not even considering change. So that's a big part of our work to get them there. And we use motivational enhancement as that first intervention in therapy to try to help move them along.

Dr. Nina Mafrici 

Sure, go for it. Okay. So, so part of improving that readiness amongst clients when they're coming in, therapists really need to explicitly state that the purpose of therapy is to help them understand their eating disorder and just decide what if anything they want to do about it. And that's really from a motivational enhancement sort of play highlighting the need to balance this with medical care for safety. So there might be some non negotiables, which we'll talk about that we require as an individual is making a decision about whether they're actually going to engage in this type of therapy and really deepening the understanding of these functions of the eating disorder. We're going to show you how we do that on a case conceptualization map, and also the client's higher values, right, and also higher goals in basically, to create some dissonance between these two, right? How is the eating disorder holding you back? For for instance, being able to graduate or be able to pursue medical school, as you want to do it, right? When you're constantly in and out of hospital, or you're not able to feed yourself, or your brain is starved and you're not able to concentrate, we also really want to give time to understand what worked and didn't work in past treatment experiences. So not uncommonly, do we have a lot of folks that have experienced trauma as a result of several eating disorder treatments in the past. You know, for instance, being hospitalized, having to be on an NG tube, has been highly traumatic for some of our young adolescents who then come to see us when they're 17, 18, 19, after a relapse being being very fearful about treatment, because they felt that a lot of it was outside of their control due to the health and safety risks when they were younger. Speaking about these treatment non negotiables, so really, this is about creating a plan to ensure that the client has medical safety while also working to maximize the client's autonomy, right? So typically is, is what we call sort of that primary non negotiable, and this might include things like dietetic support that we require, or parental involvement, regular weight checks, logging Of meal and food, and really this model of using non negotiables supports both the client and clinician within a collaborative relationship. The important thing to remember here is that these non negotiables have to have a sound rationale. So we need to provide information to the client around why we are making this non negotiable, and usually that's resulting from, you know, the evidence that we know to be true about some of the medical risks around eating disorders. We also want to make sure that there's no surprises we're not, you know, suddenly saying, after four weeks, well, now you have to go see a dietician, and that was the requirement from the start of the program. That's not the case. And we want to make sure there's consistency in the delivery. So when we're holding a non negotiable, we can't just be swayed the next week when the individual comes and says, Oh, you know, I didn't get to the doctor this week, even though that was a condition of them beginning treatment with us. So the clinician Team Stance is critical. This is also partly why we rely so heavily on our multidisciplinary team and having rounds that keep us accountable as clinicians and also help us to work through some of the tricky treatment interfering behaviors that might occur. Self monitoring is an essential part of CBTE, or CBT enhanced for eating disorders. The idea of self monitoring is that it's meant to bring attention to the exact nature of the eating problem. Becoming aware in the moment really helps us as clients, as therapists, to support our clients in changing behavior that previously might have seemed out of control or automatic, in order to be effective and most useful, these these recordings of of what an individual is eating day to day, time after time is needs to be done in the moment to be most effective, we need to address with our client the temptation for them to under over report so often in the beginning, clients may not be as forthcoming with how much they're eating or how little they're eating, or whether they're purging. So we want to address things like fears or worries about the records that are being reviewed by the therapist. What might get in the way of them completing it. Effectively, want to highlight the importance of identifying thoughts and feelings. So this is not a food log. Really important to understand a self monitoring record must include thoughts and feelings pertaining to the food or behaviors that being that are being recorded. And if the monitoring isn't completed, we really respond with sort of surprise and confusion, right? Like this is an expectation of treatment. Oh, what got in the way? Like this. This is part of part of the treatment process for you to have this done, right? This is an example of what a self monitoring record can look like. We use a number of different methods to do so good old paper and pen notes function on someone's phone. We use an app called recovery record, which allows folks, teams really like this to be able to snap pictures of what they're eating and then note things like their behaviors, thoughts and feelings, any skills that they used, it's really centered in also some DBT skills that we use to support folks when they're engaging in problematic behaviors or have high urges to engage in problematic behaviors. Gonna move it on to you. Michelle, yeah, perfect.

Dr. Michele Foster 

So some interventions that we use, this is kind of just a summary of what we're going to talk about, so we can push past it, and then I'm going to talk a little bit about DBT. First. One of the things that we address in DBT, whether it's for eating disorders or not, is the idea that every behavior, even if it's a problematic behavior, it serves a function. People do it for a reason, right? So like I said before, eating disorders are partially ego syntonic. There's something about them that's working. It's hard to give it up, and that's what makes it so difficult to treat, right? Or that's what makes them so difficult to treat, and at the same time, we can't treat something that we don't understand, and it can feel highly invalidating for folks, for us to just push through and not take the time to understand what's going on, why it's scary to let go of the eating disorder, how it's helping them, and how they got there in the first place, right? If you don't consider that, and you don't actually take the time to allow your client to feel heard and validated, it's going to be much, much harder to get them motivated and engaged in treatment. So we always spend time focusing on that and understanding it at the beginning. We even sometimes ask clients to write a letter or write out, what are the reasons that they are holding on to the eating disorder? How did the eating disorder develop? What is it helping for them? And then we also move to talking about the other side. But first we really want to flush that things that the eating disorder often helps with emotion regulation, like we mentioned, it's. Great form of distraction, right? It takes up a ton of space. Social power. So often we know that people can acquire a sense of social power via appearance, by that thin ideal that we often have seen in society. Athleticism, right? So sometimes there are things that certain body types afford people in terms of athleticism or performance, especially in those more esthetic based sports that we see, so things like ballet or gymnastics, rowing, even a number of things. Sexual abuse history, right? So sometimes even making the body smaller or taking back control of the body can be helpful for folks who have experienced abuse in different forms. And so we want to help people find the balance between accepting for them why the eating disorder developed, what it has been helpful for, and recognizing at the same time that there's a reason they're here, there's a reason that they are struggling and pushing towards change so that we can get them healthy, we can reduce the risks and actually deal with what's underneath. So sometimes what we do when working with folks with eating disorders is we develop a conceptualization of the eating disorder for them. Now this is one example, but often what we do is we take the eating disorder, kind of in the middle, and we look at the different types of dysregulation that it's causing for an individual. So emotion dysregulation is often demonstrated by things like cognitive dysregulation, relational dysregulation, self dysregulation and behavioral dysregulation, and often we'll map it out, kind of like this on a whiteboard or something with a client. And it can take up to a session to really build this for them, to help them understand. But Nina, if you'll do me a favor and move to the next slide, it's a bit simpler, and I think it might help illustrate it. So for example, when I might say to a client, how does the eating disorder affect your regulation of your behavior? And they might say something like, Well, you know, I'm often lashing out at people, and I'm often isolating myself because I really just don't want to be around people. You know, a lot of activities have to do with food, and I just don't want to deal with that. So there's this level of dysregulation within their behavior, right? Even behaviors like purging or restricting, like that, can also go under there. We'll see cognitive dysregulation. So how are your thoughts dysregulated because of the eating disorder? Well, you know, people will say to me, I spend probably 90% of my day thinking about food, weight, body, appearance, and that's really not who I am, and that's really not how I want to be, and I could do so much more if I wasn't, if my brain wasn't occupied with that, right? So that's a really, a really common example of cognitive dysregulation, but we can also see things like misconceptions about self and their beliefs and yeah, a variety of different sort of black and white thoughts around food, appearance, weight, body, etc, interpersonal dysregulation. So how is the eating disorder causing dysregulation in their relationships? So we'll often see things like disconnection or withdrawing from friends, avoidance of social events we might see. You could see, I mean, up top, we talked about lashing out, but we could see changes in relationships that leaning towards people, perhaps who are also struggling with eating disorders, is a really common one, versus actually connecting, or staying connected with folks that may be better for their recovery. And then we also see something that we call self dysregulation, and that has to do with the sense of self, right? And eating disorders, if you think about like a pie chart, they take up a big portion of that pie chart for a lot of people. And so you see this dysregulation of the self where there tends to be at times, acting against values. So things like, you know, my eating disorder made me not go to my mom's birthday party because I was too nervous about being forced to eat cake, right? Or it might be an overvaluation of appearance or weight in how an individual sees themselves, or what's most important about themselves. So with clients, we try to map this out, and it can be a really helpful way to enhance motivation for them, but we also do it in the context of looking at the larger picture of their life, so their environment, their strengths, their health, right different things that are interplaying with all of this, because we also want to hone in on what their strengths are that are going to push them towards recovery and help them actually start challenging this without that piece, this whole thing can feel kind of heavy and invalidating, so we really want to make sure to take time to pull on the strengths

as well. So.

Dr. Michele Foster 

So other things that we do in DBT - chain analysis, if anybody needs examples of chain analyzes, and you know different tools there, there are tons online, and we're happy to send them around. But basically what we do here is we map out all of the links in the chain that led to a problematic behavior like purging or a decision to restrict, and then the consequences of that, right? So we look at the thoughts, the behaviors, environmental factors, emotions, all of it. We map it all out so the client can see it, and then we go back and we look at a solution analysis. And often we'll give this to them so they can actually work on it the next time something similar comes up, we'll teach different distress tolerance skills, and often we do this in a group format, but sometimes we do it individually with clients as well, depending on what their unique needs are. So we'll talk about different ways to actually avoid a problematic behavior. So the goal here isn't to regulate the emotions with distress tolerance, it's to actually teach a skill to help them avoid engaging in problematic behavior. So we might use the Accept skill in DBT, that is, you know, comprised of a variety of different distraction tools, just to help them get through that moment. So it's not about avoiding, it's about getting through the moment. We'll use the tip skill pros and cons, right, which we might actually complete in session with a client and give them to keep so they have it on their phone or whatever. It's kind of beyond the scope and timing of this specific presentation to go into the details of each one of these things, but we do encourage you to look it up, because they're helpful tools, kind of, if your clients really struggling with strong urges. And then we also teach different emotion regulation skills, so like the PLEASE skill at the bottom here, is all about the building blocks. So we help people attend to making sure they're eating properly as much as they can, and progressing towards that. So that might be, you know, to start introducing something at breakfast if they haven't been right, that might be the first step to help regulate their emotions. We're also looking at things like sleep and appropriate exercise, substance use, managing their medications appropriately. We're looking at helping them identify and actually label their emotions and their needs, different things like expressing validation for themselves, opposite action to urges, which then also helps change emotions. So there's a variety of very concrete skills that will weave in for people, kind of depending on on what their needs are, that are drawn from DBT. In DBT, we also teach mindfulness, right? So we really want them to help understand their own pattern, understand what the difference is between their emotion mind, their reasonable mind and their wise mind, which is sort of the blend of the two. And very often, we'll see things like those purging behaviors occur when somebody is really in that extreme emotion mind. So what does that look like for them? And how can they start to recognize when they're in that? How can they start to recognize judgments about food in their body? And can we point those out? And what can we do with them? You know, how do we replace those judgments? How do we shift them? So I'm giving you, like, a whole summary, kind of of the different elements of DBT that we draw from, this would be done over, you know, many sessions, and we just sort of pick and choose based on what the clients need, unless we're going in a very structured way with clients who are in group. And, you know, we try to meet clients where they're at and base it on, really what the priority is for them. For some it might be stabilization and weight. For others, it might be comorbid self harm. It really could vary, stopping purging, right? So you kind of have to take it case by case. And the last thing I'll highlight here around DBT is values work. So understanding their own core values, that's part of their identity, really exploring how, at times, the eating disorder might be pulling them away from that, and so then starting to build this discrepancy for them so they can recognize in the moment. Okay, I feel like I'm being pulled this way. But actually, I know that, like me, myself, not the eating disorder, I would want to do this. So an example might be, you know, if I value friendship, a consistent example, so a time when I acted consistently with that this week was I spent time with Rosa, even though I had a strong urge to isolate that made me feel really happy and also anxious, right? So there's that, that dialectic there, and then an inconsistent example from this week was I avoided Tanya's party because of the fear about the foods and social anxiety, and I felt relieved 40% but I felt sad 60% right? And then we might look at that, and we might talk a little bit of about the differences in the emotions and what led to one versus the other, etc. So that's an example of how we might weave in values work around eating disorders. And then, at times, we also weave in cognitive behavioral strategies. And so when Nina was talking about the the self monitoring records you saw that there was a column there for looking at thoughts. And so that jives really well with many of these CBT strategies, where we might look at cognitive distortions, or we might call them ways of thinking that are unhelpful for the client. And so it's not that these are wrong per se, but it's about how they're looking at things and whether that's effective or helpful for them or not so things like magnifying or labeling or all or nothing, thinking and trying to help them replace judgments or these ways of thinking with things that are a little more factual, a little more descriptive and and gentler. Essentially, we work at finding the middle path or can or the considering the continuum. Essentially, so if somebody is describing themselves as I'm unattractive, right, what does it mean to be attractive? And is that a judgment? And how do you define that, right? And why is it so black and white, and just trying to flush some of these ideas and labels out a little bit more so that folks can start to challenge them better in their day to day life. At times, we'll use thought records, and we definitely also use food and body image exposure, so bringing certain types of food into session, eating them together, processing any emotions and fears that come up. And again, as we said, it's not necessarily about food, but you do, at times, still have to have those conversations about food so you can push through it and then help clients see that they can work on the emotion that's coming up with it. So we might use food hierarchies to help with that, right? So establish a list of things and then start working with them in session. It's not uncommon for us to go into grocery stores together, to cook meals together, to eat together, and to really start challenging all of that. And there's quite a bit of modeling that happens around that too. So that's just an example of what one might look like. So those, I would say, are kind of some primary interventions that we use in eating disorders. It's certainly not all of them. But the goal here is to give you a sense of a couple of different options. Probably several of you have some in your pocket already, but this just might help you expand them a little bit,

Dr. Nina Mafrici 

yeah. And I would say probably the one thing that we're not able to touch on in this presentation would be more of the body image work, which is usually more of a stage two treatment intervention with our eating disorder population. That's because, you know, firstly, it's about medical stabilization, physical stabilization. It's really, really difficult for clients to engage in that body image work when their brain is starved, when they haven't met sort of the required caloric intake or weight status that is needed. But there's a whole gambit that could be a whole other lengthy presentation in and of itself. But we're going to move on to the last part here, which is around involving other people in care. So whether you are working with clients individually who struggle with eating disorders, we need to take into account that usually there is another team that's also working hand in hand with you, or if they're not, we want to consider how we can involve those so this includes both the medical team, also families and caregivers as well as dietitians. So first piece I'm going to mention, because we talked about a little bit earlier with adolescents, is the involvement of parents and caregivers when we're not doing family based therapy, which is evidence based treatment for anorexia or bulimia or their eating disorders, for adolescents specifically, and this is when parents are really taking control of the child's eating and serving, you know, serving as as the main sort of agent for change here, when we're not doing that family based therapy, we're aiming to involve parents in the care of adolescents and young adults in many other ways. So this can be included in supervising meals, in monitoring things like attend, like going into bathrooms to prevent purging or restriction, supporting dysregulation at mealtime. So serving as a coach, sort of in these moments, ensuring adherence between sessions. So attending appointments, and really we're looking at parents and caregivers as being an essential tool to eating disorder to positive eating disorder recovery. So FBT may be used for younger ages and has several benefits and risks. It's not effective or appropriate for all families or eating disorder presentations, as with any kind of treatment, and it really, as I said before, involves the parents taking full control. All of the child's eating and helping them return to their healthy weight. The therapist in FBT is really serving as a coach right meeting with the parents, caregivers and child together at all times, working hand in hand with the dietician to set the meal plan. And you'll notice that most hospital based programs that we have for adolescents for eating disorders, use the FBT model so things like at Sick Kids North York General Hospital all are rooted in FBT for the treatment of eating disorders. Some common tips that we give for all caregivers are things like avoiding talking about weight, food, calories, or dieting at home, modeling appropriate eating or body related behaviors. So you can probably guess there's a number of challenges that come up here for a lot of kids that we're working with, and parents who have their own disordered eating, or just their own sort of values around food, we really strive to get parents on board with having all types of food at home, avoiding labels associated with food. So good, bad, junk, treats, that sort of thing, refraining from alternative meals unless medically indicated. We work with a lot of kids without severe allergies, some who are vegan or vegetarian. Really, really important to have a dietitian and physician involved in that care so that we can appropriately make sure that they're meeting the nutritional requirements and also not avoiding things due to, you know, due to the eating disorder, but claiming that it's because of, you know, an intolerance for whatever reason. We want to also ensure that caregivers are engaging in appropriate levels of physical activity, that they're modeling healthy body image, they're removing the scale from the home, right? So if we are weighing, and we're not going to go into that here, but we do have sort of requirements around weighing that is done by a professional, unless it's absolutely not possible and a parent has to take a weight for us, we're expressing concern at appropriate times, so the dinner table or around food and snacks is not a time to get into the nitty gritty about eating disorders. It's a time to really, really encourage an individual to complete their meal or to complete their snack, even if this requires them to engage in some distraction techniques, as Michelle talked about earlier, we want to avoid talking about appearances, both criticisms and compliments as these reinforce that over evaluation of body image or body and appearance and its connection to self worth, we want to focus on I statements, right? So I'm concerned because you seem to be struggling instead of you should have gotten over this by now. Or why are you doing this to us as a family? Eating Disorders take a significant toll on families. Many families come in completely dejected from previous treatment or trying to handle things on their own, so really, having the support available to them is necessary. Collaboration with the medical team, so whether in house or not, you know, it was only in the past year and a half that we've had medical practitioners on our team, but before then, we did a lot of collaboration with external providers. We really need a baseline assessment of the eating disorder severity, and this is not just getting on a scale and calculating a BMI, although BMI is going to be part of the calculation with the medical team, we need things like weight charts to determine if an adolescent has fallen off their growth chart. Have they experienced weight loss in a short period of time? Do they have amenorrhea? Are they purging? Is there any abuse of laxatives or diuretics? Heart related symptoms, all of that really needs to be understood through blood work, ECG, blood pressure, orthostatic vitals, so the connection with the GP or practitioner is essential. We get consent for disclosure of personal health information with their practitioner, with their primary physician within the first session that's needed. We ask about the last physical we want to see you know what has been said about their blood work? ECG, if they don't have a GP, which a lot of people don't these days, unfortunately, we have to refer them to a walk in or a nurse practitioner. So we really do need that medical information. We also work very hand in hand with dietitians. So dietitians with specialized training in eating disorders really important that they have experience with eating disorders. We've seen it not go as well when they're seeing sort of a general dietitian in the community. That's not because the general dietitian doesn't have the knowledge or skill, but actually oftentimes, because the individual seeing them tends to downplay their eating disorder concerns. So they might be given something like, you know, a new meal plan because their tummy hurts every time they eat gluten, and they might be told, Well, we're going to take you off gluten, which is actually counter intuitive to the eating disorder treatment process. So the role of dietitians in eating disorder treatment, they assess caloric intake. They determine sort of what is their need for weight gain, maintenance or loss, symptom management, improving relationship with food, normalizing eating by giving a specific meal plan that we can support individuals in following nutrition education, meal planning skills, grocery shopping skills, cooking skills, to help support them in that as well as helping them to determine food exposures and outlining their hierarchy. Nutrition is a crucial part of the eating sort of recovery process. So we've talked about a lot about emotions, but we still have to target the food avoidance and all of sort of the the associations with food that can be problematic. Importance of a meal plan really essential. So it's really difficult to do eating disorder treatment if you don't have a meal plan that you, as a therapist and the client are well versed in. It helps to provide structure, accountability, assess, weight gain progress or other nutritional deficiencies, and especially for adolescents, is allows the parents and family to have a clear understanding of the expectations of what their child needs to be eating throughout the recovery process. The meal plan is continuously revised depending on where the client is in their stage of treatment. So it's important that it's not just a one off assessment, but a client is regularly meeting with a dietitian to update that as needed. So effective eating disorder treatment can't occur in silos. It really relies on that ongoing close collaboration between providers, client family. So wherever you are providing eating disorder treatment, you need to make sure you have those connections with those other providers. Monitoring progress also and outcomes is an essential part of providing evidence based treatment. And so we use a range of psychometric the EDQ the EDQLS. These are eating disorder measures assessing things like quality of life, assessing how an individual sees their current eating problems and behaviors. We also ask for qualitative reflections of initial treatment goals from the client and the family, and we look at these typically at the beginning of treatment, about three months into treatment, and every three months thereafter, until the termination of treatment, weight status and other physical health measures are also tracked. So we use a weight progress chart, especially with our adolescents who have restrictive eating disorders, and we establish, with collaboration between the dietitian and the physician a wellness weight so typically, a range where they need to meet to ensure that they're on their appropriate growth curve. And this includes weight stability or no further loss. We want to make sure that they have stable vitals, and we also want to encourage healthy reintegration of physical activity when appropriate. So in the past, it used to be, you know, an individual going through eating disorder treatment absolutely no physical activity. We now know there's a lot of benefits so emotionally, physically for individuals who engage in some type of physical activity. However, it does have to be done in a monitored way. Okay.

Dr. Michele Foster 

Now, I've been typing like random stuff into the chat the entire time, but I haven't seen anything else in there, so I have no clue if people can even see it, or if I'm missing questions,

Megan W 

we can see it,

Dr. Michele Foster 

but like all the participants, can see it. Yes,

Megan W 

okay, everybody can see everything in the chat. Okay, just a quiet group. So

Dr. Michele Foster 

do you guys have any questions? You're welcome to type them in. You're welcome to, I don't know if this has raised your hand or

had a best goal about it. Yeah,

Megan W 

I think if anybody wants to, feel free to type it in the chat. I can sort of read them out or or, you know, if you guys can, can see them as well. You can jump in. I mean, I, I personally would love if you guys could talk a little bit more about the just because it's interesting to me, the the pre contemplative stage and like, the different modalities that you guys use, like DBT or motivational interviewing to, like, get somebody into that sort of place where you can start to use interventions and support them, just because it's it kind of shifted my framework, personally, in my head, of understanding like, okay, it's really just like the the understanding of what's behind the behavior is like, so there's so many factors and so many things that could go into it. So because you're starting out with that behavior of, maybe, like, restrictive eating, or whatever it may be. How do you sort of tackle it from, like, a, I guess, more of a therapy perspective, with that like body approach of, like, here's this one thing. How do we parse it back to see, like, what the root of that is when someone. In a pre contemplative stage, like, how long does that process usually take? And what sort of tools do you guys have? Yeah,

Dr. Nina Mafrici 

so it can take quite a while. I'm not going to lie. It depends on how long the individual has also been struggling. It's also why we try and get individuals into treatment earlier, because the earlier we get them, especially adolescents, the more the you know, the quicker that we respond in terms of a treatment approach, the more likely the success of recovery, particularly when we have family and caregiver involvement. There are some really great narrative strategies that are used within a motivational enhancement sort of approach in those early stages. Probably one of my favorites is writing a letter to the eating disorder. And this can be my eating disorder is my best friend, dot, dot, dot, and write a letter according to that, my eating disorder is my worst enemy. Dot, dot, dot. And that's a really awesome exploratory activity and exercise, it really gets at a lot of the roots of what Michelle was talking about, in terms of that conceptualization. You really see how things like the behavioral dysregulation, the relationship dysregulation, the self dysregulation, comes out in there, but it also helps you, as a therapist, gain an appreciation for what that eating disorder has really served in that young person or adults life. So it allows you a good place to begin exploring those in an empathic way that also allows you to challenge it, right? And as you work to build that relationship with a client, then you can, you know, use a little bit more of the irreverent strategies and humor and things like that, but I find that that is a really effective strategy in those early stages, particularly for a young person that sort of feels like they're being dragged into this and the last thing that they want to do is being told that they need to eat. Yeah,

Dr. Michele Foster 

I agree with that. And you know, I think the important thing to remember as therapists, it's not linear, so it's going to wax and wane, and you might make some progress, and it's going to slide back. And I think if you put yourself into the shoes of the the client, very often, they're focused on the end goal, well, you're going to make me gain a ton of weight, and it's going to be awful, and I'm going to be so uncomfortable, and I won't be able to tolerate it. And we want to keep them maybe like, where they're at in one step ahead, right? So by focusing on the underlying stuff and the attitudes and the values and the validation and what they need, you're you're really shifting them back and enhancing that motivation through through those conversations.

Megan W 

Thanks guys. Lots of questions coming into this, like, besides body image, what other topics are in the second phase?

Dr. Nina Mafrici 

Oh, great question. So lots of different topics, you know, I think about it a lot in terms of the stages of DBT treatment as well. So body image can be one of them. Oftentimes it's recovery from other comorbid issues. OCD, for instance, trauma processing tends to come up a lot in stage two of treatment from an eating disorder. But basically any other type of sort of heavy, kind of cognitive, involved treatment that we can't really engage in as well in those early stages while we're trying to get to a place of physical stability. So when we have an individual who comes in and they are, you know, let's say they're there, they get a clean bill of health or physically stable, but they are entrenched in some eating disorder behaviors and eating disorder thoughts. It's a little easier to weave in some of that work, to bring in the body image work into that but there's, you know, the list is really endless when it comes to that stage two work.

Dr. Michele Foster 

I'm realizing here Megan, if I don't see anything. So I think I wasn't maybe a host or something, because I'm not. I don't know if the other participants can also see the things that I was writing, but I don't see any questions. So I'm mindful of the time too, and I know that we might have missed a whole bunch throughout. So people are always welcome to reach out and and, yeah, we

Megan W 

Yeah, I think, I don't think you guys missed any questions. Okay, good, I can see all the stuff in the chat. Oh, good. I just have the stuff coming in, just sort of like, after you, after you.

Dr. Michele Foster 

Oh, okay, I can't see anything. I don't know why. Okay, so,

Megan W 

yeah, go ahead. Yeah, sorry, go ahead. I know you're mindful of time and everything. I'm happy to send you guys some of these questions. If you

Yeah, okay, yeah, we do, and we do regularly do eating disorder training workshops. They're small ones, where our next one is being launched in the new year. So people are interested in learning more, getting some more hands on strategies. It's more of a comprehensive overview of some of the bits and pieces we talked about today.

Megan W 

Amazing. Thank you guys so much. I know for myself, like I mentioned that it really sort of shifted my perspective a lot. And everybody here is just saying thank you, thank you, thank you.

Dr. Nina Mafrici 

Thank you. Thank you so much for coming out today. Yes, thank you for having us

Dr. Michele Foster 

and thank you everyone. Great to connect with you all, and we look forward to seeing you soon.

Dr. Nina Mafrici 

Thanks for the opportunity. So much. Everybody.